Social Functioning

Adolescence is also a time of social change when a young person has to establish self-identity and relationships outside the family (see Chapters 2 and 5) . Body image is important to all adolescents (36,37) and may be detrimentally affected in JIA. Generalized growth failure and pubertal retardation (38) are seen in severe JIA. Some local growth anomalies (e.g., a short digit) are often mild but may cause concern to the patient, while other anomalies, such as micrognathia, can profoundly change facial appearance. Drug therapy in JIA may also have detrimental effects. Oral corticosteroids alter the distribution of fat stores and can change skin appearance with acne, striae and hirsuitism. Chlorambucil and cyclophosphamide may cause

gonadal failure, which can have a profound effect on an individuals' perception of their sexuality.

Difficulties with relationships may persist into adulthood because of delayed social maturation. If the individual is physically dependant, there will be more reliance on friends and sexual partners to act as carers. Relationships with sexual partners may take longer to establish (39), possibly because the relationship is not just partner-to-partner but also potentially carer-to-dependant. However, a number of adults with JIA have long-term relationships with other disabled people.

Limited mobility can affect an individual's ability to participate in socializing activities and gain independence (40,41), (i.e., having to rely on parents for transport when friends are able to use a bus or train independently). The attitudes of society to physical deformity may also affect social interaction. Social life may be affected because of the restrictions on alcohol intake related to methotrexate prescription. Despite this, most children and adolescents with JIA perceive themselves as socially competent (42) and are remarkably similar to case controls on measures of social functioning and behavior (43). In adulthood, social activity reduces in the majority of patients. This becomes more marked those patients with significant physical disability (44).

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